Understanding out-of-pocket insurance costs

Written by Katie Carpenter

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Dec 10, 2013 10:19 AM

Premium

The amount that you’ll pay for health insurance, usually on a monthly basis. You’ll pay this even if you didn’t have any medical expenses that month. Usually, you pay a lower monthly premium if you have a higher deductible.

Out-of-pocket costs

These are your expenses for medical care that are not covered by insurance. These include deductibles, co-insurance, and co-payments for covered services plus any medical care that isn't covered by your plan.

Deductible

This is the amount that you are responsible for paying when you receive medical services before your health insurance plan kicks in to help pay. So, if your deductible is $1,000, for example, that means that your plan will begin covering medical costs only after you've reached that initial $1,000 in expenses. For each doctor visit or drug that is prescribed, you may have a copayment or co-insurance.

Co-payment (co-pay)

This is a fixed amount that you'll pay for a covered health care service, and it's usually paid at the time of that service. Usually, copays don't count towards your deductible. Co-pays vary by type of service. For example, a co-pay for a doctor visit might be $25, and $150 for an ER visit

Co-insurance

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan's allowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.